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<div data-role="page" class="jqm-demos ui-responsive-panel"
	id="assessmentPage" data-title="Assessment">

	<div data-role="header" data-theme="k"
		class="ui-btn-active ui-state-persist" data-position="fixed">
		<h1>アセスメントシート</h1>
		<a href="#assessment-search-form" data-icon="search"
			class="ui-btn-right">検索する</a>
	</div>

	<!-- Start Content -->
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		<div class="ui-grid-a ui-responsive">
			<table cell-padding="0" cell-spacing="0" border="1" data-mini="true"
				style="width: 100%; border-collapse: collapse; text-align: center;">
				<tr>
					<th colspan="10" bgcolor="#507EA3" style="color: white;">ア セ ス メ ン
						ト シ ー ト</th>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">理由</td>
					<td width="20%" colspan="2">変化（悪化）</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">作成者</td>
					<td width="30%" colspan="3">nomura</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">作成日</td>
					<td width="20%" colspan="2">2014/02/21 12:25:00 PM</td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">実施場所</td>
					<td width="20%" colspan="2">その他</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">更新者</td>
					<td width="30%" colspan="3">kida</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">更新日時</td>
					<td width="20%" colspan="2">2014/02/21 12:26:00 PM</td>
				</tr>
				<tr>
					<th colspan="10" bgcolor="#A8D8FF" align="left">★基本情報</th>
				</tr>
				<tr>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">氏名（かな）</td>
					<td width="20%" colspan="2">ひらのけんいち</td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">生年月日</td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">生年月日</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">年齢</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">性別</td>
				</tr>
				<tr>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">氏名</td>
					<td width="20%" colspan="2">平野 ケンイチ</td>
					<td width="20%" colspan="2">1931/01/11</td>
					<td width="20%" colspan="2">1931/01/11</td>
					<td width="10%">83</td>
					<td width="10%">M</td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left" rowspan="3">住所</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">郵便番号</td>
					<td width="20%" colspan="2">0</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">都道府県</td>
					<td width="20%" colspan="2">佐賀県</td>
					<td width="10%" bgcolor="#C8C8C8" rowspan="3" align="left">電話番号</td>
					<td width="20%" colspan="2" rowspan="3"
						style="vertical-align: middle">0X066452317</td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">住所</td>
					<td width="50%" colspan="5">佐賀市城内1-1-59</td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">建物名等</td>
					<td width="50%" colspan="5"></td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left" rowspan="2">認定情報</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">要介護区分</td>
					<td width="40%" colspan="4">要支援２</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">状態</td>
					<td width="30%" colspan="3"></td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">認定年月日</td>
					<td width="20%" colspan="2"></td>
					<td width="10%" bgcolor="#C8C8C8" align="left">認定期間</td>
					<td width="20%" colspan="2">2012/03/14</td>
					<td width="10%">~</td>
					<td width="20%" colspan="2">2013/07/15</td>
				</tr>
				<tr>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">自立度</td>
					<td width="30%" colspan="3"></td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">認知症</td>
					<td width="30%" colspan="3"></td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left" rowspan="4">被保険者情報等</td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">介護保険</td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">被保険者番号</td>
					<td width="50%" colspan="5"></td>
				</tr>
				<tr>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">医療保険</td>
					<td width="70%" colspan="7"></td>
				</tr>
				<tr>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">身体障害者手帳</td>
					<td width="30%" colspan="3"></td>
					<td width="10%" style="border-right-color: #D8D8D8;"></td>
					<td width="10%" align="left">種</td>
					<td width="10%" style="border-right-color: #D8D8D8;"></td>
					<td width="10%" align="left">級</td>
				</tr>
				<tr>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">生活保護</td>
					<td width="10%"></td>
					<td width="10%" bgcolor="#C8C8C8" align="left">受給者番号</td>
					<td width="20%" colspan="2"></td>
					<td width="10%" bgcolor="#C8C8C8" align="left">負担者番号</td>
					<td width="20%" colspan="2"></td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left" rowspan="2">利用情報</td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">初回利用日</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">利用日</td>
					<td width="60%" colspan="6">
						<table style="width: 100%; border-collapse: collapse">
							<tr>
								<td
									style="border-right: 1px solid black; border-right-color: #D8D8D8"><fieldset
										data-role="controlgroup" data-mini="true"
										data-type="horizontal" data-role="fieldcontain">
										<input type="checkbox" name="checkbox-1" id="checkbox-1"
											data-mini="true" class="custom" /><label data-mini="true"
											for="checkbox-1">月</label>
									</fieldset></td>
								<td
									style="border-right: 1px solid black; border-right-color: #D8D8D8"><fieldset
										data-role="controlgroup" data-mini="true"
										data-type="horizontal" data-role="fieldcontain">
										<input type="checkbox" name="checkbox-2" id="checkbox-2"
											data-mini="true" class="custom" /><label data-mini="true"
											for="checkbox-2">火</label>
									</fieldset></td>
								<td
									style="border-right: 1px solid black; border-right-color: #D8D8D8"><fieldset
										data-role="controlgroup" data-mini="true"
										data-type="horizontal" data-role="fieldcontain">
										<input type="checkbox" name="checkbox-3" id="checkbox-3"
											data-mini="true" class="custom" /><label data-mini="true"
											for="checkbox-3">水</label>
									</fieldset></td>
								<td
									style="border-right: 1px solid black; border-right-color: #D8D8D8"><fieldset
										data-role="controlgroup" data-mini="true"
										data-type="horizontal" data-role="fieldcontain">
										<input type="checkbox" name="checkbox-4" id="checkbox-4"
											data-mini="true" class="custom" /><label data-mini="true"
											for="checkbox-4">木</label>
									</fieldset></td>
								<td
									style="border-right: 1px solid black; border-right-color: #D8D8D8"><fieldset
										data-role="controlgroup" data-mini="true"
										data-type="horizontal" data-role="fieldcontain">
										<input type="checkbox" name="checkbox-5" id="checkbox-5"
											data-mini="true" class="custom" /><label data-mini="true"
											for="checkbox-5">金</label>
									</fieldset></td>
								<td
									style="border-right: 1px solid black; border-right-color: #D8D8D8"><fieldset
										data-role="controlgroup" data-mini="true"
										data-type="horizontal" data-role="fieldcontain">
										<input type="checkbox" name="checkbox-6" id="checkbox-6"
											data-mini="true" class="custom" /><label data-mini="true"
											for="checkbox-6">土</label>
									</fieldset></td>
								<td><fieldset data-role="controlgroup" data-mini="true"
										data-type="horizontal" data-role="fieldcontain">
										<input type="checkbox" name="checkbox-7" id="checkbox-7"
											data-mini="true" class="custom" /><label data-mini="true"
											for="checkbox-7">日</label>
									</fieldset></td>
							</tr>
						</table>
					</td>
				</tr>
				<tr>
					<td width="20%" colspan="2">2012/11/03</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">提供時間</td>
					<td width="60%" colspan="6">
						<table style="width: 100%; border-collapse: collapse">
							<tr>
								<td
									style="border-right: 1px solid black; border-right-color: #D8D8D8;"
									width="30%" colspan="3"></td>
								<td
									style="border-right: 1px solid black; border-right-color: #D8D8D8;"
									width="10%">~</td>
								<td width="30%" colspan="3"></td>
							</tr>
						</table>

					</td>
				</tr>
				<tr>
					<td width="60%" bgcolor="#C8C8C8" align="left" colspan="6">職歴・生活歴・利用動機</td>
					<td width="40%" bgcolor="#C8C8C8" align="left" colspan="4">既往歴</td>
				</tr>
				<tr>
					<td width="60%" colspan="6">&nbsp</td>
					<td width="40%" colspan="4"></td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left" rowspan="7">緊急連絡先</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">続柄</td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">氏名</td>
					<td width="30%" bgcolor="#C8C8C8" align="left" colspan="3">住所</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">同居</td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">電話/メール</td>
				</tr>
				<tr>
					<td width="10%" rowspan="2">配偶者</td>
					<td width="20%" colspan="2" rowspan="2">平野麗美</td>
					<td width="30%" colspan="3" rowspan="2">ひがしそん</td>
					<td width="10%" rowspan="2">1</td>
					<td width="20%" colspan="2">&nbsp</td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
				</tr>
				<tr>
					<td width="10%" rowspan="2"></td>
					<td width="20%" colspan="2" rowspan="2"></td>
					<td width="30%" colspan="3" rowspan="2"></td>
					<td width="10%" rowspan="2"></td>
					<td width="20%" colspan="2">&nbsp</td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
				</tr>
				<tr>
					<td width="10%" rowspan="2"></td>
					<td width="20%" colspan="2" rowspan="2"></td>
					<td width="30%" colspan="3" rowspan="2"></td>
					<td width="10%" rowspan="2"></td>
					<td width="20%" colspan="2">&nbsp</td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left" rowspan="11">関係支援先</td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">施設名</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">担当者</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">職種</td>
					<td width="10%" bgcolor="#C8C8C8" align="left">カテゴリ</td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">電話番号</td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">メール</td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="20%" colspan="2"></td>
					<td width="20%" colspan="2"></td>
				</tr>

				<tr>
					<td width="20%" colspan="2">&nbsp</td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="20%" colspan="2"></td>
					<td width="20%" colspan="2"></td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="20%" colspan="2"></td>
					<td width="20%" colspan="2"></td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="20%" colspan="2"></td>
					<td width="20%" colspan="2"></td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="20%" colspan="2"></td>
					<td width="20%" colspan="2"></td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="20%" colspan="2"></td>
					<td width="20%" colspan="2"></td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="20%" colspan="2"></td>
					<td width="20%" colspan="2"></td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="20%" colspan="2"></td>
					<td width="20%" colspan="2"></td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="20%" colspan="2"></td>
					<td width="20%" colspan="2"></td>
				</tr>
				<tr>
					<td width="20%" colspan="2">&nbsp</td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="10%"></td>
					<td width="20%" colspan="2"></td>
					<td width="20%" colspan="2"></td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">備考</td>
					<td width="90%" colspan="9"></td>
				</tr>
				<tr>
					<th colspan="10" bgcolor="#A8D8FF" align="left">★健康状態</th>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">内服</td>
					<td width="90%" colspan="9"></td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">アレルギー</td>
					<td width="90%" colspan="9"></td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">バイタル</td>
					<td width="30%" colspan="3"></td>
					<td width="20%" bgcolor="#C8C8C8" align="left" colspan="2">バイタルメモ：</td>
					<td width="40%" colspan="4"></td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">留意点</td>
					<td width="90%" colspan="9"></td>
				</tr>
				<tr>
					<td width="10%" bgcolor="#C8C8C8" align="left">特記事項</td>
					<td width="90%" colspan="9"></td>
				</tr>
				<tr>
					<td width="100%" colspan="10">さんだん花ガーデン デイサービス</td>
				</tr>

			</table>
		</div>
	</div>
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	<div data-role="panel" data-position="right" data-display="overlay"
		data-theme="a" id="assessment-search-form" style="width: 75%;">
		<div data-role="fieldcontain>
					<form        action="form.php"
			method="post" data-mini="true">
			<div data-role="fieldcontain" data-mini="true">
				<label for="name" data-mini="true">氏名:</label> <input type="text"
					name="search-scs" data-mini="true" id="text-hcs-id" value=""
					placeholder="" data-theme="f"> </br> </br> <label for="name"
					data-mini="true">住所:</label> <input type="text" name="search-scs"
					data-mini="true" id="text-hcs-id" value="" placeholder=""
					data-theme="f"> </br> </br> <label for="name" data-mini="true">ID:</label>
				<input type="text" name="search-scs" data-mini="true"
					id="text-hcs-id" value="" placeholder="" data-theme="f"> </br> </br>
			</div>
			<div data-role="fieldcontain">
				<fieldset data-role="controlgroup">
					<input type="checkbox" name="checkbox-1" id="checkbox-1"
						data-mini="true" class="custom" data-theme="f" /> <label
						for="checkbox-1" data-mini="true">有効な利用者のみ表示する</label> <input
						type="checkbox" name="checkbox-2" id="checkbox-2" data-mini="true"
						class="custom" data-theme="f" /> <label for="checkbox-2"
						data-mini="true">過去のシートも表示する</label> <input type="checkbox"
						name="checkbox-3" id="checkbox-3" data-mini="true" class="custom"
						data-theme="f" /> <label for="checkbox-3" data-mini="true">アセスメントシートが無い利用者も表示する</label>

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			<a href="#" data-role="button" data-mini="true" data-theme="j"
				data-icon="search">検索する</a>
			</form>
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		<div class="ui-body ui-body-h ui-corner-all"
			style="height: 450px; overflow: auto;">
			<table data-role="table" id="table-custom-2" data-mode="columntoggle"
				data-mini="true"
				class="ui-body-d ui-shadow table-stripe ui-responsive"
				data-column-btn-theme="b" data-column-btn-text=" Select "
				data-column-popup-theme="a">
				<thead>
					<tr class="ui-bar-h">
						<th data-priority="2">選択</th>
						<th>氏名</th>
						<th data-priority="3">性別</th>
						<th data-priority="1"><abbr>Assment No</abbr></th>
						<th data-priority="5">HCS ID</th>
					</tr>
				</thead>
				<tbody>
					<tr>
						<th>1</th>
						<td><a href="#frmContactEdit" data-rel="popup"
							data-transition="slideup">藤本 明日</a></td>
						<td>F</td>
						<td>8</td>
						<td>KANA-000001</td>
					</tr>

					<tr>
						<th>2</th>
						<td><a href="#frmContactEdit" data-rel="popup"
							data-transition="slideup">新垣 さとみ</a></td>
						<td>F</td>
						<td>11</td>
						<td>KANA-000002</td>
					</tr>
					<tr>
						<th>3</th>
						<td><a href="#frmContactEdit" data-rel="popup"
							data-transition="slideup">平野 ケンイチ</a></td>
						<td>M</td>
						<td>3</td>
						<td>LKAN-000001</td>
					</tr>

					<tr>
						<th>4</th>
						<td><a href="#frmContactEdit" data-rel="popup"
							data-transition="slideup">梅村 美菜</a></td>
						<td>F</td>
						<td>6</td>
						<td>LKAN-000002</td>
					</tr>

					<tr>
						<th>5</th>
						<td><a href="#frmContactEdit" data-rel="popup"
							data-transition="slideup">梅村 美菜</a></td>
						<td>F</td>
						<td>16</td>
						<td>LKAN-000008</td>
					</tr>

					<tr>
						<th>6</th>
						<td><a href="#frmContactEdit" data-rel="popup"
							data-transition="slideup">梅村 美菜</a></td>
						<td>F</td>
						<td>26</td>
						<td>LKAN-000023</td>
					</tr>

					<tr>
						<th>7</th>
						<td><a href="#frmContactEdit" data-rel="popup"
							data-transition="slideup">梅村 美菜</a></td>
						<td>M</td>
						<td>32</td>
						<td>LKAN-000009</td>
					</tr>

					<tr>
						<th>8</th>
						<td><a href="#frmContactEdit" data-rel="popup"
							data-transition="slideup">梅村 美菜</a></td>
						<td>M</td>
						<td>11</td>
						<td>LKAN-000021</td>
					</tr>

					<tr>
						<th>9</th>
						<td><a href="#frmContactEdit" data-rel="popup"
							data-transition="slideup">梅村 美菜</a></td>
						<td>M</td>
						<td>346</td>
						<td>LKAN-000048</td>
					</tr>

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						<th>10</th>
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							data-transition="slideup">梅村 美菜</a></td>
						<td>F</td>
						<td>14</td>
						<td>LKAN-000034</td>
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